Resolving ADHD testing claim dispute between provider and insurance?

Hello all,

I have CareFirst BCBS through my employer in Maryland and sought ADHD diagnostic testing through a provider in Virginia, which is the state I reside in.

My provider and the insurance company have been going back and forth regarding the claims associated with the series of testing sessions I underwent a few months back. Basically, as I understand it, my provider submitted the claim with certain "procedure codes" and the insurance company responded with a request that the provide also submit some required documentation for that code, i.e. a treatment plan and notes.

This is where the issue began — according to the provider, they do not create those documents when the procedure is just diagnostic testing. The provider responded to the insurance company saying as much, and apparently things have just deadlocked from there — provider saying they don't have those documents and insurance telling them they're required and to either submit them or resubmit the claim under a new "procedure code."

After a while, my provider got me involved and had me reach out to the insurance company — which as you might expect didn't really change anything. I got the same response from the insurance and relayed that to the provider — what else could I really do? I'm just a lay-person, after all.

So, now, my provider is sending me the bill for the outstanding amount.

I'm not exactly sure how to proceed from here. I'm trying to persuade my provider to continue their appeal process and potentially have both of us (myself and the provider) jointly call the insurance company and see if our combined efforts might yield something better.

Additionally, during my conversations with insurance, they informed me per my Explanation of Benefits (EOB) that I am not liable for any outstanding amount not covered by insurance. I'm not entirely sure what that all means, to be honest. My provider is in-network with CareFirst and I believe, because of that, they have a prior payment agreement or something? Really not sure here, like I said I'm just a layperson.

So to the crux of the ask — what can I do here? I worry that if I pay the provider's bill out-of-pocket, any claim I make with the insurance company for that money will be summarily denied because, technically, I wasn't liable for that money in the first place per my EOB.

I'm frustrated with all this as it seems like they're fighting over technicalities? Like, procedure codes? A treatment plan? Come on. This shouldn't be so difficult!

Thanks in advance for any thoughts / ideas!

submitted by /u/ggutierrez545
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